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Decided: November 6, 2015

In a black lung benefits case, the Fourth Circuit found that the Administrative Law Judge’s (ALJ) decision applying the fifteen-year presumption to the claim did not reopen an earlier claim, and thus did not contravene separation of powers.  The Fourth Circuit also found that the ALJ did not improperly use the fifteen-year presumption to establish that a condition of entitlement had changed since the earlier claim was denied.  On this basis, the Fourth Circuit upheld the finding of the Benefits Review Board (BRB) awarding benefits to Arvis Toler, and denied Eastern Associated Coal Corporation’s (Eastern) petition for review of the BRB’s decision.

Toler worked in Eastern’s West Virginia mines for 27 years, 16 of them underground and exposed to high concentrations of coal dust.  From 1966 to 1997, Toler also smoked about a pack of cigarettes per day.  In the mid-1980s, Toler began to have shortness of breath, and by 1993, Toler’s health was so bad, he had to leave his coal mining job.  Toler’s health, however, continued to decline.  By 2000, he used supplemental oxygen, and by 2008, he used oxygen 24 hours per day.

The Congressionally created black lung benefits program provides benefits to coal miners and their dependents for miners who are fully disabled due to pneumoconiosis, a respiratory disease stemming from exposure to coal dust.  To obtain benefits, a miner must show that he has pneumoconiosis, that the disease arose from coal mine employment, that he is totally disabled, and that the pneumoconiosis contributes to his total disability.  In 1972, Congress amended the Act to provide a presumption of total disability for a coal miner who worked underground for at least 15 years, and had a totally disabling respiratory/pulmonary problem.  The presumption was repealed in 1981 for claims filed on or after January 1, 1982, but reenacted in March, 2010 for claims filed after January 1, 2005 and pending on or after March 23, 2010.  The reenacted presumption could be rebutted by establishing that the miner did not have legal or clinical pneumoconiosis stemming from coal mine work, or that no part of the total disability was caused by pneumoconiosis.

Toler filed his first black lung benefits claim shortly before leaving Eastern in 1993.  The ALJ denied the claim, finding that Toler was totally disabled by pulmonary disease, but that he failed to show it was coal mine work (as opposed to smoking) that had caused the disease.  The denial was upheld by the BRB and by the Fourth Circuit.  In 2008, Toler filed a second black lung benefits claim.  This time, the parties stipulated that Toler was a coal miner, and was totally disabled by pulmonary disease.  Applying the 15-year presumption, the ALJ found that the only remaining issue was whether Eastern could show Toler did not have pneumoconiosis.  Finding that Eastern failed to do so, the ALJ granted Toler benefits.  Eastern appealed to the BRB, which remanded to the ALJ for Eastern to rebut the 15-year presumption.  The ALJ again granted Toler’s claim for benefits, finding that Eastern did not rebut the 15-year presumption.  Eastern again appealed to the BRB, this time on the basis that in deciding the second claim, the ALJ improperly reopened Toler’s first claim violating finality and res judicata, that the 15-year presumption could not be used as a change of condition of entitlement required to submit a new claim for benefits, and that the ALJ used an improper rebuttal standard.  The BRB found against Eastern, and upheld the grant of benefits to Toler.  Eastern appealed, arguing that applying the 15-year presumption in the second claim violates separation of powers by reopening the earlier claim, and that the 15-year presumption cannot be used to establish a change in conditions of entitlement necessary to file a second claim.

The Fourth Circuit first held that the presumption could be used to show a change in a condition of entitlement.  The Fourth Circuit based this holding on the language of the Act and regulations, the language of the preamble to the 2000 Final Rule, and on deference to the Secretary of Labor.  Further, the Fourth Circuit found that Toler submitted new physical evidence with his second claim for benefits.

The Fourth Circuit then held that the application of the presumption to the second claim did not allow Toler to reopen a final decision.  The Fourth Circuit based this holding on case precedent holding that a subsequent claim for benefits is not the same as a previous claim.  On the basis of these holdings, the Fourth Circuit affirmed the BRB’s grant of benefits to Toler, and denied Eastern’s petition for review.   

Full Opinion

Katherine H. Flynn